Tag: leadership

Trust in Voluntary Reporting

Hard data is immensely useful. Now there’s a surprise. That’s facts and figures. That’s accurate descriptions of occurrences. That’s measurements and readings of important factors. From this kind of data, a picture can be painted of events good and bad. However, this picture is not complete. It’s certainly not complete for any system that involves the interactions of humans and machines.

What’s often less visible is the need for what I might call – soft data. As such it’s not “soft”. I’m just using that loose term to distinguish it. Fine, you could say that social media is littered with the stuff. Vast qualities of instant judgements and colourful opinions. An array of off-the-shelf solutions to life’s ills. That’s all well and good for entertainment. It’s not so useful as a means of getting to the truth.

In civil aviation voluntary reporting systems have been around for several decades. They are not always successful, mainly because there’s a fair amount of trust required to use them when something major happens. When volunteering information there needs to be a level of assurance that the information will not be misused.

The human inclination to seek to blame is intrinsic. We wake-up in the morning, look out the window, and if it’s rainy and windy then someone is to blame. Probably a weather reporter for not warning us of a coming storm. Blame is a way of making sense of negative events without having to do lot of tedious investigation and analysis.

Don’t get me wrong. Accountability is vital. If someone does something unspeakably bad, they must be held accountable. That is a form of blame. Tracing the bad event back to the root cause. If that cause is found to be negligence or malicious intent, then blame can be assigned.

Where a good safety culture exists, as it often the case in civil aviation, then it is wrong to assume that undesirable outcomes can always be linked to a bad actor of some kind.

Human error is forever with us. Even with the absolute best of intent no one is immune from this pervasive creature. It can be illusive. There are environments where owning up to making mistakes is fine. Sadly, I’m sure it’s not uncommon to have worked in environments where such openness is punished. The difference between a good culture and a bad one.

One of my past jobs involved negotiation with a contactor. Every change that we made to a complex contact had a cost attracted to it. So, there was an understandable sensitivity to making changes. At the same time our customer for the product kept asking for changes. There’s nothing worse than being in a tense meeting with a contactor and having my boss pull the rug from under my feet. Seeking to blame a change on my error rather than a customer request. Introducing a voluntary reporting system in such an environment is pointless.

My message here is clear. Voluntary reporting in aviation is a powerful tool. Reports submitted by employees can offer insights that are not available by just looking at hard data. These reporting systems maybe required by regulation or company policy. However, without a good sound safety culture they can be all but useless. A safety culture that is defended and supported by employees and the senior management of an organisation.

Shifting Perspectives

Daily writing prompt
What’s a topic or issue about which you’ve changed your mind?
View all responses

If you write the perfect rule, you will get the desired outcome. Authoring a specification that is robust and watertight will assure success. Having the best possible plan will deliver the best possible results. All sounds reasonable – doesn’t it? It’s not surprising that someone like me, having been schooled in project management, and working in engineering, would have a rational and systematic approach to problem solving. A proven highly successful way of implementing complex technical projects and delivering successful outcomes.

As an analogy I’ll start with mathematics. Nature is a curious beast. What we lean about complex systems is that what happens is highly dependent upon a start point. The initial conditions. Graduate level mathematics about control systems with feedback show that their behaviour changes a lot with a change of initial conditions. So, it’s reasonable to extend that to a systematic approach to just about anything. It’s often true.

Fail to plan – plan to fail. That idiom is a simple few words to sum up this cause and effect. Used by famous names and often quoted. Management training books are littered with this notion.

20-years ago, my team introduced the first European Aviation Safety Plan[1]. This initiative was built around the idea that to achieve a common objective a plan is the best and quickest way to get there. A roadmap, a pathway, a strategy, call it what you will.

Start by identifying problems and then propose a fix for each one. Not all problems but the ones that fit that awkward Americanism – the low hanging fruit. Namely, the biggest problems (fruit) that can be solved with the least effort (easily picked).

Here’s where I’ve changed your mind. Maybe not changed in a dramatic sense but shifted perspective. It’s essential to have a plan, even if it’s just in my head, but it can be overstated as the most important part of a process of change.

The Plan, Do, Check, and Act (PDCA) cycle, starts with a plan. It must start that way. However, each of the four steps is equally important. Seems obvious to say. Even so, it’s often the case that a press release, or alike, will state – we have a plan, roadmap, pathway, strategy, as if that’s the job done.

Management teams will smile with a sense of achievement and show off their plans. A decade down the line that celebration might seem less momentous as the “do” part of the process turns out to be harder than anticipated.

This basic model for systematic change is a good one. Where I’ve changed my emphasis is in the distribution of effort. Don’t put all available energies into constructing the perfect plan. Yes, the initial conditions are important but they are not everything. The key part of the process is the cycle. Going around it with regularity is a way of delivering continuous improvement. Afterall, when it comes to a subject like aviation safety, that’s what’s needed.

[1] 2005 – DECISION OF THE MANAGEMENT BOARD ADOPTING THE 2006 WORK PROGRAMME OF THE EUROPEAN AVIATION SAFETY AGENCY

Addressing the Root Causes

How do you get people out of a miserable funk? It does seem to be where we are now. Wealthier and healthier than past generations only to be gloomy.

For all their faults, advertisers and marketers are perceptive at times. A Weetabix breakfast cereal advert[1] captures what I’m writing about in these short lines. A tweed jacketed professor stands in front of an audience of the “great and the good” to exclaim that Britain’s performance has been sliding downhill. Citing examples, he then goes on to offer a theory. No prizes for guessing his editable cure all. It’s an understated use of humour. It’s a sideways look at the silliness of mixing-up correlation and coincidence. Which happens all the time on social media.

“We must rebuild Britain”. There’s a fine slogan that could grace a political campaign. At least it’s positive. At least it’s about addressing causes, fixing problems and making stuff.

Time to draw a distinction. A symptom can be an indicator. A sign, or what’s believed to be a sign. A cause is a reason for a problem. The root or source.

My view of the current political landscape is that we are spending lots of time and energy chasing symptoms, many of which are entity false. Symptoms can be an easy hit. A target to blame. Newspaper headlines full of negative stories all add to feelings of sliding downhill. Only in analysis, hidden in the small print, are there stories and theories about causes. Getting to the root of a problem is a hundred times more difficult than scratching the symptoms.

The treacherous right-wing brand of divisive and destructive politics, that is toping the opinion polls, does nothing to solve real problems. That recipe is only a way of creating more problems. More gloom.

The “ungodly” foolish proposal to kick-out hard-working people who contribute to this country is idiotic. A term I borrowed from the fictional character Simon Templar, as The Saint. It’s a term aimed at those whose morals are virtually non-existent. Fighting the ungodly doom mongers is necessary. A higher calling is to propose a better way.

Frankly, I don’t believe that the majority of this country’s people are mean and thoughtless in the way some unscrupulous politicians think. Even so, a lingering danger exists. Just as the advertisers and marketers can turn our heads so persistent negativity has a grinding effect.

Removing the miserable funk of the moment isn’t going to happen by chasing the funk. Flooding the country with more funk. Burying the country in funk.

We must rebuild Britain by accentuating the positive. Confidently fixing problems.

The Weetabix TV advert I referenced above featured a man pointing at a pothole. It may sound trite. It’s been a feature of campaigns over the years. There’s a real everyday problem that we know how to fix. What’s been disappointing is the fact that we know that, and have always known that, but the problem persists. Let me suggest that a route to a more positive outlook would be to remove the cause of people’s annoyances. Stop starving local government. Give them a solid mandate, backed up by resources, to fix what we know can be fixed. Purge at least one problem. If we need more hard-working people to do the job, I think I might know where to find them.

[1] https://youtu.be/T2ZZiIeuwRE

Communication Prevents Disasters

It’s often forgotten that there’s a need to repeat messages. We are not creatures that retain everything we see and hear. There are exceptional people, it’s true, those who cram away facts and have an amazing level of recall. Often that’s my reaction to watching students leading teams on University Challenge[1]. How on earth do they know those obscure facts?

Most of us do not respond well to those who say, “Well, I told them once. I’m not going to tell them again.” That line is probably one of the most misguided utterances a teacher can make. Like it or not, this approach is part of our heritage. Past ages, when deference was expected, listening was mandatory, and misremembering was entirely the listener’s fault.

We’ve had a cultural shift. Our complex technological society doesn’t work in a command-and-control way. Too many disasters can be traced to miscommunications and misunderstanding. Now, the obligation exists on those delivering a message to go some way to ensure that it’s received with a degree of comprehension. That’s when repetition has a role to play.

One of the pillars of Safety Management Systems (SMS) is Safety Promotion. It’s the Cinderella of the aviation safety world.

Why do I say that? Experience for one. It’s much easier to get policy made and funding for the “hard” sciences like data acquisition, analysis and decision-making systems. These are often perceived as providing tangible results. Actionable recommendations that satisfy the need to be recognised as doing something. Even if that something is questionable.

Communication is key to averting disasters. It’s no good having pertinent information and failing to do anything with it, other than file it. The need to know is not a narrow one. Confined to a specialist few.

Let’s go back to 2003 and the Space Shuttle Columbia accident[2]. This craft was destroyed in a disaster that claimed the lives of its crew. The resulting investigation report is extremely compressive, if slightly overwhelming, but it has some key points to make.

To quote, “That silence was not merely a failure of safety, but a failure of the entire organization.” [Page 192]. In other words, the hidden concerns and internal machinations of an organisation can smother safety messages and led to failure. Since 2003, it’s sad to say that there are multiple occasions when what has been learned has been ignored. The impact has been devastating.

So, to shape the future let’s remember the Cinderella of the aviation safety. Discovering problems is not enough. It’s vital that practical solutions and good practice gets promoted. That needs to be done forcefully and repetitiously.

NOTE: This is, in part, a reaction to watching this video presentation. https://acsf.aero/an-unforgettable-closing-to-the-2025-acsf-safety-symposium-with-tim-and-sheri-lilley/

[1] https://www.bbc.co.uk/programmes/b006t6l0

[2] https://ntrs.nasa.gov/api/citations/20030066167/downloads/20030066167.pdf

Just Culture

My thought is that we’ve forgotten the discussion of more than a decade ago. There was a time when the thoughtful reflections on responsibility and accountability were much discussed.

Without focusing on specific examples, there are plenty to choose from, there’s the propensity of our institutions and politicians to reach for “blame” as a first response. When situations go bad the instinctive inclination to hunt out someone to blame. This is an all too prevalent habit.

Naturally, in cases, there’s the strong need to identify who is accountable for bad decisions. Society does not like it when the powerful protect, cocoon themselves and grab for immunity. Certainly, some people and organisations are genuinely blameworthy. However, if we scrutinise and point the finger of blame, it doesn’t help if that finger is pointed at a person’s honest errors. There isn’t a human on this planet who hasn’t made an error.

The finger of blame is easily pointed. Judgment so often falls after an event. The time when more is known, and hindsight comes into play. This tips the balance. It’s so much easier to say: why on Earth did you do that? I would never have done that.

For people to come forward and be fairly heard in an open and fair inquiry or investigation they need to have the confidence that they are not stepping into a public blame-fest. Without trust between those on all sides of it’s less likely that the truth will come out.

“Just Culture” is a concept written into aviation legislation and followed by others. The overriding aim is to learn from mistakes. It’s the surest way of not repeating the same mistakes time and time again. It’s beneficial to have that long-term learning objective. Why suffer the pain of a bad event when the means to avoid it are known and understood?

Now, I’m going back 20-years. I remember being part of an international working group[1] called GAIN. The group compiled guidance about organisational culture. At the time, the group was considering the subject in the context of the air traffic profession. Guidance like the one referenced, emphasise that a Just Culture is not simply a no-blame culture. It’s not, and never has been a way of circumventing accountability.

Determining culpability can be complex. There’s often a test to consider the wilfulness of the participants in a bad event. In other words, did they carelessly, intentionally, maliciously or negligently make decisions that resulted in the bad event? In these cases, the “they” could be an individual or an organisation.

Gross negligence, wilful abuses and destructive acts should be addressed by the enforcement of laws. If we say the criminalisation of honest people involved in bad events has a negative impact. That is not to negate the need for enforcement. Regulators in all sorts of walks of life have a duty to apply enforcement where and when it’s appropriate. Maybe we ought to have applied that to the UK water industry.

My plea here is to first consider the nature of the events in question. Was there an element of genuine honest human error? Is the right balance being struck between the need to learn and the need to ensure accountability?

NOTE: Just Culture is defined in EU law as “A culture in which operational staff or others are not held accountable for actions, acts, omissions or decisions commensurate with their experience and training, but gross negligence, intentional violations and destructive actions are not tolerated” EC 376/2014 Art. 2 Para. 12.

[1] A Roadmap to a Just Culture https://flightsafety.org/files/just_culture.pdf

Safety Culture 2

This may sound at variance with my last blog. I hope it’s not. I hope it’s complementary. What I’m highlighting here has been observed over decades of contact with a wide variety of organisations.

The term safety culture is fused into the pillars of ICAO Annex 19. The essence of building a good safety culture that fosters sound practices and encourages communications, in a non-punitive environment is at the heart of standards and recommended practices. With all those decades behind us the reader might assume that there’s unambiguous and well aligned attitudes and ways of working throughout the aviation industry. That’s not so.

On a spectrum of what could be called hard to soft the manner of application of know best practices can take different forms. By the way, please disassociate those two words with both easy and difficult. That’s not what I mean.

In my interpretation “hard” means like pages of Niccolo Machiavelli’s The Prince[1]. Aggressive, persistent, mandatory, uncompromising and all encompassing.

In my interpretation “soft” means like pages of The Little Book of Calm by Paul Wilson[2]. Harmonious, enlightened, progressive, sympathetic, and understanding.

As with extremes on any scale, going to the ends of that scale are not the best way to operate. I say “best” in terms of getting to ways of working to endure with engagement and effectiveness. I observe much of this depends on how power is disseminated through an organisational structure. Highly hierarchical organisations will approach culture differently from organisations with a relatively flat management system.

It may not be surprising to suggest that aviation Authorities can veer towards the “hard” approach and staff Unions towards the “soft” approach. Even when both are trying to reach the same goal. Where people come from a military background, command and control can be an instinctive reaction. Where people come from an advanced technology company background, collaboration and communication can be an instinctive reaction. In my observation there are advantages in both a hard and soft safety cultural approaches.

One advantage of a hard safety culture is that the time between discovery of a safety problem, taking corrective action and resolving that operational problem can be short. Clearly, that has distinct safety advantages. Certain airlines come to mind.

One advantage of a soft safety culture is that there can be the discovery of safety problems that would otherwise remain hidden. Where collective ownership of the problem is not in question. Again, clearly, that has distinct safety advantages too. Certain manufacturers come to mind.

I guess my message is as per much ancient thinking. All things in moderation. Try to reap the benefits of both ends of the scale. Balance.

[1] https://www.londonreviewbookshop.co.uk/stock/the-prince-niccolo-machiavelli

[2] https://www.waterstones.com/book/the-little-book-of-calm/paul-wilson/9780241257449

GE2024

Let me spectate. I’m no professional commentator, pollster or political pundit but do try to keep myself up to speed with the current affairs. The question in the mind of a lot of people is: when will the next UK General Election take place?

In these days before Christmas, it’s possible the Prime Minister (PM) doesn’t even know the answer to this question. It’s a balance of how strategic or opportunist he will be when it comes to making such big decisions. Most current predictions are that the Conservatives are destined to be defeated. The gap in the national opinion polls is substantial. That makes the decision of timing of an election one that could mark the end of the current PM’s term of office or elevation to Conservative saviour. Currently, political parties are desperately selecting candidates for each constituency. Something is afoot. Better stop there before I get tempted into a pun.

Let’s put aside any consideration of a winter vote. Arctic weather gloom hovers like cold mist. With the prospect of large heating bills upsetting most of the population there’s no politician who will want to accept the blame for that situation. Naturally, they will say that they are working at pace to tame inflation and overseas conflicts are the root of the pain.

The first step on the road ahead is next year’s springtime. Local elections are expected. Every year, they take place on the first Thursday in May. This is when a third, or less of the electorate put a cross in a box. At the same time London’s next mayor will be elected. So, 2nd May 2024 will be like a mini political barometer. Real votes in real ballot boxes are always a better indicator than sampling or sage views.

The European Parliament election is scheduled for 6th to 9th June 2024. You may think this European Union (EU) election has no bearing on the UK, but I beg to differ. If there’s a significant advance of right-wing political parties across Europe, then the impact will be felt in the UK.

The 2020 United States (US) presidential election was quite a show. In prospect, for the 2024 US presidential election is a gripping event despite the weak selection of candidates. That US national election is scheduled for Tuesday, 5th November 2024. Guy Fawkes day[1] in the UK.

Let’s assume the Conservative party will want to hang on, not to the bitter end, but to get as much time elapsed after the pandemic shockwave, Partygate, mini budget madness and the cost-of-living crisis as they can. We are still reeling from the post-Brexit political earthquakes that have trashed confidence and the economy. Will the cost of government be political exile? That all said, people have shifted a long way since last year. The big question is: who do you trust?

The UK’s Labour party opposition should be confident and smiling. However, the opposition probably feels aggrieved having to wait so long for others to fail before getting an opportunity to win a general election. What doesn’t help is that the electorate are now pessimistic about any sustained recovery. Sadly, the public mood is beset with quite a sense of decline-ism.

Traditionally, in the UK, September is party conference season. That leaves October open for an election. But as noted above there’s a news media attention getting clash between what’s happening in the UK and US. Since significant geopolitical tensions are going to be raging throughout 2024, I think that topic may not be an influencing factor on the UK election date question.

Rolling the dice as late as October 2024 has several advantages for the incumbents. If there’s good summertime news, say inflation reduced and a modicum of economic growth the government will claim a great success. The struggle between democracy or autocracy around the globe could give a UK PM a platform on which to make one or two grand gestures. Also, with nearly a year to go, the opportunity for the opposition parties to trip-up increases.

When polls ask is Britain a better place to live than it was ten years ago or a worse place to live than ten years ago the pointer points at worse. It’s hard to imagine this will not impact voter intentions. 

#ukpolitics #ukpolitics #politics #generalelection

[1] https://www.parliament.uk/about/living-heritage/evolutionofparliament/parliamentaryauthority/the-gunpowder-plot-of-1605/overview/people-behind-the-plot/guy-fawkes-/